Nursing Elites

1. A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.

• A. Use open-ended questions to encourage client dialogue
• B. Offer opinions about the necessity for adequate nutrition
• C. Focus on the client's self-disclosure about food preferences
• D. Identify the reasons the client has for not wanting to eat

Correct answer: B

Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.

2. An LPN/LVN is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to:

• A. Demonstrate confidence in the client's ability to deal with stressors
• B. Provide hope and reassurance that the problems will resolve themselves
• C. Display an attitude of detachment, confrontation, and efficiency
• D. Provide authority, action, and participation

Correct answer: D

Rationale: When caring for a suicidal client, providing authority, taking action, and encouraging the client's participation in their care are essential. Choice A is incorrect as it may not be sufficient for the critical situation of a suicidal client. Choice B, while offering hope, may not address the immediate risk of harm. Choice C's attitude of detachment and confrontation can be counterproductive in establishing trust and rapport with the client. Therefore, the most appropriate intervention is to provide authority, take action to ensure safety, and involve the client in the care process.

3. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.

4. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)

• A. Purchase a gun to use for protection.
• B. Keep quiet and calm.
• C. Take a self-defense course that retaliates against the abuser with injury.
• D. Have a bag ready that has extra clothes for self and children.

Correct answer: C

Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.

5. A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?

• A. Weight gain.
• B. Sexual dysfunction.
• C. Nausea.
• D. Constipation.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.

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